Summary

Findings. There continues to be strong backlash against the idea of digital vaccine passports and potential 

vaccine mandates. A growing number of businesses, including colleges and universities, airlines, cruise lines, 

and sports venues, say that they will require proof of vaccination for entry or services. However, about half of the 

U.S. population strongly opposes any type of vaccine verification system, with consumers largely divided along 

party lines. Additionally, coverage of vaccine hesitancy is increasing as the media reports that vaccine supply 

exceeds demand in some communities and recent data suggests that vaccine demand and coverage may 

plateau as soon as late April. News and social media coverage of hesitancy, vaccine surplus, and the looming 

threat of not reaching population immunity may undermine intentions to vaccinate by fostering the perception 

that controlling COVID-19 is outside one’s control.

Ways to take action. Federal, state, and local partners should continue to work together to increase 

transparency, respond to gaps in information, and confront misinformation with evidence-based messaging. 

The goal of these efforts is to increase confidence in COVID-19 vaccines and expand vaccine uptake more 

broadly. Efforts should be made to continue to amplify information about the safety and effectiveness of 

COVID-19 vaccines. 

COVID-19 State of Vaccine 

Confidence Insights Report

Report 6 | April 28, 2021 | Date Range: April 12–26, 2021

The findings and conclusions in this report are those of the author(s) and do not necessarily represent the official position of the Centers for Disease Control and Prevention (CDC).

Contents

1 Summary

2 Aims and Methods

3 Vaccine passports and mandates polarize 

consumers and politicize the broader 

vaccination effort

4 Coverage of vaccine hesitancy and other 

threats to population immunity increase

5 Emerging Themes

7 Continuing and Evolving Themes

8 Appendix: Inputs and Sources

Centers for Disease Control & Prevention, 

COVID-19 Response, Vaccine Task Force

Vaccine Confidence Team, Insights Unit

CS000000-A | 04/30/21
Page: 2

COVID-19 State of Vaccine Confidence Insights Report | Report 6 | April 28, 2021

Aims and Methods

By rapidly reviewing and analyzing numerous sources and inputs (see , the biweekly COVID-19 State 

of Vaccine Confidence Insights Report emphasizes major themes that influence COVID-19 vaccine hesitancy 

and uptake. These are characterized by level and type of threat to vaccine confidence, degree of spread, and 

directionality. By examining how consumers think and feel, social processes, and the practical issues around 

vaccination, the Insights Report seeks to identify emerging issues of misinformation, disinformation, and places 

where intervention efforts can positively impact vaccine confidence across the United States.

Appendix)

The information in this report is only a snapshot, and certain populations may be underrepresented. Images and 

quotes are illustrative examples and are not meant to be comprehensive of all content related to the highlighted 

themes.

Theme Classification

How do you classify this theme/information?

High risk Moderate risk Low risk Positive sentiment

 May lead to vaccine

refusals and decreased 

uptake

Wide reach, pervasive

Potential to trigger 

hesitancy to vaccinaton

Moderate reach, modest 

dissemination

Concerning, but low risk 

to vaccine confidence

Limited reach, limited 

dissemination

Could increase vaccine 

confidence, intent, or 

motivation

Variable reach and 

dissemination

How has this theme/idea changed over time (since last report or over the course of multiple reports)?

Increasing 

Information spreading rapidly

Stable 

Information remaining 

constant at prior level

Decreasing

Information is not gaining further 

traction and there has been no 

indication of additional activity
Page: 3

COVID-19 State of Vaccine Confidence Insights Report | Report 6 | April 28, 2021

Major Themes

Vaccine passports and mandates polarize consumers and politicize the broader 

vaccination effort.

There continues to be strong backlash against the idea of digital 

vaccine passports and potential vaccine mandates. A growing number 

of businesses, including colleges and universities, airlines, cruise lines, 

and sports venues, say that they will require proof of vaccination for 

entry or services.1,2

 However, about half of the U.S. population strongly 

opposes any type of vaccine verification system, with consumers 

divided along party lines.3,4 Conservative leaders criticize and oppose 

the passports and have proposed a bill to ban the federal government 

from requiring such documentation.5,6

 A growing number of states 

have pre-emptively prohibited proof-of-vaccination systems.7,8,9

Consumers who identify as conservative and those in the "wait and 

see" group are against the idea of vaccine passports or mandates in 

any situation.10,11 Meanwhile, among healthcare employees who said 

they did not intend or had not decided to get vaccinated, more than 

80% said they would oppose a vaccine requirement.12,13 Nearly twothirds of respondents said they would rather leave their job than get a 

COVID-19 vaccine.14,15

High levels of media volume indicate that consumers are confused 

about potential vaccine passport rules and documentation 

requirements16 —even as some private employers require their 

workers to get vaccines or announce that vaccination is a condition 

of employment.17,18,19 The American Civil Liberties Union (ACLU) and 

others urge caution over vaccine passports, noting that such systems 

hold potential to exclude members of the population, such as those 

who are medically underserved and those who are experiencing 

poverty.20,21 The ACLU further notes that vaccine passports stand 

to alienate populations with reason to fear such systems, such as 

immigrant communities and communities of color.22,23 A confusing 

and politicized proof-of-vaccination system could undermine trust 

in health systems and make already hesitant consumers less likely to 

get vaccinated24,25,26 —even as some private employers require their 

workers to get vaccines or announce that vaccination is a condition 

of employment.27,28,29

Ways to take action:

 Support research to better understand how proof-of-vaccination systems may contribute to or undermine vaccine confidence

and the population’s willingness to get vaccinated. Gather information on people’s thoughts and feelings toward sharing 

private health information and on appropriate message framing to explain the rationale for such systems.

Partner with states and jurisdictions to plan how to create and implement equitable and accessible proof-of-vaccination 

systems. Conduct rapid community assessments to learn more about the structural and practical barriers that proof-ofvaccination systems may raise. 
Page: 4

COVID-19 State of Vaccine Confidence Insights Report | Report 6 | April 28, 2021

Coverage of vaccine hesitancy and other threats to population immunity 

increase.

While some U.S. regions are working to address ongoing 

vaccine access and eligibility issues, others are working to 

fill empty appointment slots and grappling with vaccine 

supply exceeding community demand. Reports of unfilled 

appointments have surfaced across the country, particularly 

in areas with a noted high degree of hesitancy, such as rural 

areas.30,31 Compared to those living in suburban and urban 

areas, fewer people in rural areas plan to get vaccinated.32

These reports are borne out by polling data, which show that 

hesitancy issues are greatest in rural communities.33,34

Recent analysis suggests that vaccine demand and coverage 

may plateau much earlier than expected, even as soon as 

late April.35 Such a plateau would indicate hesitancy and 

low vaccine uptake — both threats to reaching population 

immunity. The “magic number” needed to reach population 

immunity is variable and, as of yet undefined.36,37,38 The lack 

of clarity leaves interpretation of population immunity 

milestones open for debate. A subset of state leaders 

announced that their communities were approaching 

population immunity due to vaccinations and naturally 

occurring infections, despite words to the contrary from 

public health experts.39,40 Increased coverage of hesitancy, 

vaccine surplus, and the looming threat of not reaching 

population immunity stands to undermine intentions to 

vaccinate by fostering the perception that controlling 

COVID-19 is outside one’s control. 41

Ways to take action:

 Partner across federal agencies to model and determine

explicit vaccination coverage targets for the United States. 

Measure and update consumers on progress toward 

coverage goals on an ongoing basis. Clear and transparent 

coverage goals stand to build trust in the healthcare 

system, encourage accountability, improve measurement 

of confidence and demand-building efforts, and promote 

equitable distribution and uptake of COVID-19 vaccines.

Continue to feature consumer vaccination 

stories, including information about personal 

motivations, challenges, and concerns. Work with 

partners to identify trusted messengers and influencers who 

can share their personal stories both on personal and shared 

platforms. Partner with technology companies to amplify local 

vaccination stories.

Amplify messages about how consumers can talk to their friends and family about vaccination. Develop and disseminate tools 

for consumers and organizations to talk about COVID-19 vaccination online and offline. Engage the COVID-19 Community 

Corps in mobilizing these messages in their communities.

Source: https://static1.squarespace.com/static/5f7671d12c27e40b67ce4400/t/607

5bc376125561b742e9ff5/1618328632135/Final+Press+Release-Surgo+Ventures+G

en+Pop+Followup+Survey+%281%29.pdf
Page: 5

COVID-19 State of Vaccine Confidence Insights Report | Report 6 | April 28, 2021

Emerging Themes

Women are experiencing unique and increased side effects after 

vaccination.

There are a growing number of media reports of women being 

more likely to experience side effects and experiencing different 

side effects than men.42 More reports of headaches, fatigue, 

dizziness, and rashes at the site of infection were made for 

women than men, according to data in the Vaccine Adverse 

Event Reporting System (VAERS).43 This sex difference could be 

the result of a disproportionate number of women reporting 

to VAERS (differential reporting), biological differences, or even 

gender bias in clinical trials.44,45 Following vaccination, a subset 

of women report experiencing atypical menstruation, including 

changes in timing and nature of menstruation.46 Such reports 

have been co-opted and incorporated into misinformation 

narratives that warn of a link between COVID-19 vaccination and 

infertility.47,48

Of the reported cases of CVST following vaccination with J&J/

Janssen COVID-19 Vaccine, nearly all occurred in women of 

reproductive age.49 Therefore, some experts have suggested 

reserving the J&J/Janssen COVID-19 Vaccine for men only 

and that the adverse events may be linked to hormonal 

differences.50,51 Others argue that doing so would be premature 

while researchers continue to examine the issue.52

Ways to take action:

 Conduct further research on women’s health needs and COVID-19 vaccines, including irregular menstrual cycles following

vaccination. Empower healthcare professionals to relay information about vaccine safety to patients; strengthen their capacity 

to have empathetic vaccine conversations. Offer healthcare providers and trusted advocates content prioritized for female 

patients concerned about vaccine safety and effectiveness.

Partner with healthcare professionals to address misinformation clearly and transparently about COVID-19 vaccines, fertility, 

and reproductive health — especially those healthcare professionals who provide care to women.

. 

Source: COVID vaccine: Women report more side effects than men. Here's why. 

(usatoday.com)
Page: 6

COVID-19 State of Vaccine Confidence Insights Report | Report 6 | April 28, 2021

Emerging Themes (cont.)

Attention to side effects and potential adverse events for all COVID-19 vaccines is 

increasing.

In the United States, consumers continue to report experiencing side effects and potential adverse events for all three COVID-19 

vaccines.53,54 As these reports continue, especially in light of the J&J/Janssen COVID-19 Vaccine pause, vocal vaccine deniers are 

seeking to amplify concerns about side effects and cast doubt on vaccine safety.55,56

Ways to take action:

 Share clear, complete, and accurate messages about COVID-19 vaccine safety to build trust in the vaccines, healthcare

professionals, and the health system. Provide regular updates on what is known and unknown about the safety and side 

effects of COVID-19 vaccines, as well as the broad benefits of vaccination.

Consumers are receiving mixed messages about asymptomatic 

spread after vaccination.

After mixed messaging on whether fully vaccinated people carry 

the virus causing COVID, CDC clarified that further research, CDC 

clarified that more research is needed to fully understand the role of 

vaccinated people and COVID-19 cases.57,58 Such messaging further 

muddles guidance for fully vaccinated people, especially in regard 

to testing, activities and travel with children, and asymptomatic 

spread. Both vaccinated and unvaccinated people are questioning 

whether they can spread the virus that causes COVID-19 and what 

safety measures are still necessary following vaccination.59

Ways to take action:

 Clearly explain and expand guidance around COVID-19 testing

guidance clearly and thoroughly for vaccinated people, especially 

considering breakthrough cases.

Regularly update the public about asymptomatic spread of the virus that causes COVID-19 among fully vaccinated people as 

more information becomes available.
Page: 7

COVID-19 State of Vaccine Confidence Insights Report | Report 6 | April 28, 2021

Continuing and Evolving Themes

Themes below have been noted in Reports 1 through 5 and continue to undermine vaccine confidence. For additional context 

and previous recommendations on these themes, see previous Insights Reports.a,b,c,d,e

 Equity and access issues. Barriers to vaccination persist among non-English-speaking and immigrant populations. Barriers

include site-specific identification requirements (e.g., driver’s licenses, Social Security numbers, health insurance cards) and 

lack of interpreters for consumers not fluent in English. Although everyone can receive a COVID-19 vaccine regardless of 

immigration status, there are reports of people without identification being turned away from sites.60,61 New ways to take 

action: 

Share clear messages widely that all people can receive a COVID-19 vaccine, regardless of immigration status. Deploy 

trusted messengers to amplify this message for people with unauthorized or undocumented status and for non-US-born 

people.

Variants and breakthrough cases. There continue to be breakthrough cases of COVID-19 in vaccinated people throughout 

the United States.62,63 As research seeks to determine the role of variants in breakthrough cases, vaccine companies are 

exploring the possibility of COVID-19 booster vaccines for vaccine variants.64 New ways to take action:

Share clear, complete, and accurate messages about COVID-19 virus variants, breakthrough cases, and actions that 

consumers need to take to promote health and safety.

Travel. Consumers are confused about CDC’s updated travel guidance,

65,66 which discourages nonessential travel but states 

that fully vaccinated people can travel at low risk to themselves and others.67 Confusion about family travel persists as parents 

are unsure how to travel with unvaccinated children or if it is safe to do so.68 New ways to take action:

Clearly explain guidance around the risks and safety precautions still needed for fully vaccinated adults. Expand the 

guidance to explain the risk and safety considerations for fully vaccinated adults traveling with unvaccinated children. 

Generation Z. COVID-19 vaccination uptake and interest continue to lag among Generation Z young adults, and vaccine 

messaging geared toward this demographic from state or federal public health officials and broadcast to social media is 

generally lacking. There is a dearth of innovative content developed outside of official public health channels that prioritizes 

and considers the unique needs of this demographic.69,70 Develop tailored content and disseminate through messengers that 

Gen Z trusts.
Page: 8

COVID-19 State of Vaccine Confidence Insights Report | Report 6 | April 28, 2021

Appendix: Inputs and Sources

Type Input Cadence Sources Tactics for Utilization

Mixed 

Methods

Communication Surveillance 

Report

Daily, 

weekdays

Google news

 Meltwater

CrowdTangle

Native platform searches

 Share of voice topic analysis to identify 

themes

 Emerging topics 

Tanaq Social Listening +Media 

Monitoring Report

Virality Report

Weekly  Meltwater

 Muck Rack

 Sprout Social

 First Draft

 Stronger

Native platform searches

 Trending topics

Demographic and geographic conversation 

monitoring

Meltwater Daily  Facebook, Twitter, Instagram

 Blogs

News media

Online forums

 Share of voice topic analysis

 Emerging theme topics

Identify high reach/velocity topics

Social 

Media 

Listening

OADC Channel COVID-19 Post 

metrics

Weekly  Sprout Social

Native OADC account analytics

Analyze # of posts, topics 

 Success of messages, # of impressions, 

reach, # engagements

OADC Channel Comment 

Analysis

Daily, 

weekdays

Native platform searches  Sentiment analysis

Identify message gaps/voids

CrowdTangle content insights 

report

Biweekly  Facebook  Top pages (voices), groups

General trends/sentiment analysis

News analysis through posts

FEMA Social Listening Report Daily Hootsuite

 Brandwatch

CrowdTangle

 Meltwater

 Trends/sentiment analysis

National and global news analysis

Direct 

Reports

CDC-INFO Metrics Weekly, 

Mondays

CDC-INFO inquiry line list

 Prepared response (PR) usage 

report

Cross-compare PR usage with inquiry 

theme analysis

 Sentiment analysis

Identify information gaps/voids

VTF Media Requests Weekly, 

Mondays

 Media request line list  Leading indicator for news coverage

Identify information gaps/voids

Web Metrics Weekly, 

Wednesdays

 Top pages

Google search queries

 Top FAQs

 Referring domains

Identify information gaps/voids,

Identify keywords/search terms, changes in 

web traffic

Research

Poll Review Weekly, 

Mondays

Harris Poll, PEW research, Gallup 

Poll, KFF 

Identify socio-behavior indicators related 

to motivation and intention to vaccinate 

Literature Review 

Science updates

Weekly, 

Mondays

 PubMed, LitCovid, ProQuest Central 

CDC’s COVID-19 Science Updates

Identify key COVID-19-related studies 

on epidemiology, clinical treatment and 

management, laboratory science, and 

modeling with implications for vaccine 

confidence

a Insights Unit, Vaccinate with Confidence Team. State of vaccine confidence report: Report 1. Atlanta, GA: Vaccine Task Force, Centers for Disease Control and Prevention; 2021.

b Insights Unit, Vaccinate with Confidence Team. State of vaccine confidence report: Report 2. Atlanta, GA: Vaccine Task Force, Centers for Disease Control and Prevention; 2021.

c Insights Unit, Vaccinate with Confidence Team. State of vaccine confidence report: Report 3. Atlanta, GA: Vaccine Task Force, Centers for Disease Control and Prevention; 2021.

d Insights Unit, Vaccinate with Confidence Team. State of vaccine confidence report: Report 4. Atlanta, GA: Vaccine Task Force, Centers for Disease Control and Prevention; 2021.

e Insights Unit, Vaccinate with Confidence Team. State of vaccine confidence report: Report 5. Atlanta, GA: Vaccine Task Force, Centers for Disease Control and Prevention; 2021.